2001_1121 /1/2,i.✓ i' e �e(
WATER ga-'
Issued: 11- ,21-0J Finished: �_o/ Employee:
Grid map: _�---
Name: talk rCi. Address: —.13 a (a —z LDCc
Phone Number. CO ,�; PAW. 4%/ (WK):
Check for. Accuracy test: Meter Leak: Check water pressure:
Initial meter relocation inspectioes Re -read
1. Backflow Insy. 2. BAWL 3. Maintenance 4. Qxh
Backflow Insp. A. Main Line A. Pump A. Line Locate
Bkflow Cert. Date B. Valves B. Water Tower B. Line Locate
Re -Cert Date C. Service Line C. Samples C. Tap
D. Hydrants D. Equipment D Excavation
E. Safety
S. Reason for failure: A. Electrolysis B. New Construction C Poor Installation D. Other
6. List of safety egaiptneat at site if applicable:..
A. Barricades B. Cones C. Tape D. Lights
\ E. Other
Request for Services: ( ryr,o , � a\ l
7. If Me::r: Se-.ice Leak: Cass_, City: / Customer
A. Water Loss (estimate): GPM Fire plug flushing Total Gallons
B. Wu Water Metered: Yes No
C. Wu Customer Notified: Verbally Doorlmockcr-
Vehicle/Equipment Used
8. If M:::: C:a.:g: Out: Unit R Miles Hrs Equipment
A. Oid Meter '4 Gt J'S"132. Reading /2,33
B. New Meter Z S /2 ems(, 4 Reading - �e-
C. Old Meter Size/Type: 4 %3 / o " D New Meter Size/Type s j x /'7
E. Type of work performed or findings: e K 2 tt s . D A° 4' /z c - Jo)
•
9. If mainline or deep service r -,air, describe type of pipe or service line and condition:
10. Man - hours: .? . d Crew Members. u/.4ie4 d /1! ty
It. List Materials Used:
12. If You had t- accide.:u?- cede -t while performing this reques:. Did you report .t' Yes or no
13. water Laltaes -tear: irspe: :cc : or fail
14. How atany trips to do task? 2 . - -
Signature/